A nurse is assessing a child and notes Koplik spots. In which of these communicable diseases are Koplik spots present?

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Question 1 of 5

A nurse is assessing a child and notes Koplik spots. In which of these communicable diseases are Koplik spots present?

Correct Answer: B

Rationale: Koplik spots are small white spots with a bluish-white center on the buccal mucosa (inside the cheeks). They are a characteristic finding in measles (rubeola) and are considered an early sign of the disease. Measles is a highly contagious viral infection that primarily affects children. In addition to Koplik spots, other symptoms of measles include fever, cough, runny nose, and a characteristic rash that typically starts on the face and spreads to the rest of the body. Vaccination is an effective way to prevent measles and its complications.

Question 2 of 5

A school nurse observes a child, with a peanut allergy, in obvious distress, wheezing and cyanotic, after ingestion of some trail mix containing peanuts. Place the interventions the nurse should implement in order of the highest priority to the lowest priority. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d).

Correct Answer: c

Rationale: The highest priority intervention in this situation is 'C': Promptly administer an intramuscular dose of epinephrine. Epinephrine is The first-line treatment for anaphylaxis, which is a severe allergic reaction that can be life-threatening. Administering Epinephrine as soon as possible can help reverse The symptoms and stabilize The child.

Question 3 of 5

A preterm newborn, after spending 8 weeks in the NICU, is being discharged. The parents of the newborn express apprehension and worry that the newborn may still be in danger. How should the nurse interpret these statements?

Correct Answer: A

Rationale: It is normal for parents of preterm newborns who have spent time in the NICU to express apprehension and worry upon discharge. The NICU experience can be stressful and overwhelming for families, and it is common for parents to feel anxious about taking their newborn home. The nurse should provide support and education to help alleviate the parents' concerns and ensure a smooth transition from the hospital to home. It is important to acknowledge the parents' feelings, offer reassurance, and reinforce the importance of follow-up care and monitoring.

Question 4 of 5

Which is the most appropriate nursing intervention for the newborn who is jittery and twitching and has a high-pitched cry?

Correct Answer: C

Rationale: The most appropriate nursing intervention for the jittery and twitching newborn with a high-pitched cry is to obtain serum glucose and serum calcium levels (Option C). These symptoms are indicative of possible hypoglycemia or hypocalcemia, which are common issues for newborns. Monitoring glucose and calcium levels will help identify and address any imbalances that may be causing these symptoms. Administering glucose (Option D) may be necessary if hypoglycemia is confirmed, but it should be based on the results of blood tests. Monitoring blood pressure (Option A) and obtaining a urine sample to detect glycosuria (Option B) are not the priority interventions in this scenario compared to assessing serum glucose and calcium levels.

Question 5 of 5

The screening test for PKU is most reliable if the blood sample is:

Correct Answer: D

Rationale: The screening test for PKU (Phenylketonuria) is most reliable when the blood sample is fresh and taken from the heel. This is because the test requires a small amount of blood, and obtaining a fresh sample from the heel minimizes the risk of contamination and ensures accurate results. Additionally, collecting the blood sample from the heel is less invasive for the newborn and is a common practice for newborn screening tests. Blood samples taken from cord blood, 14 days after birth, or before oral feedings are initiated may not provide accurate results for the PKU screening test.

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